Wolters Kluwer Health
may email you for journal alerts and information, but is committed
to maintaining your privacy and will not share your personal information without
your express consent. For more information, please refer to our Privacy Policy.

Abstract: A 77-year-old woman presented with shortness of breath 1 year after a right upper lobectomy for lung cancer. She showed a possible intracardiac metastasis on positron emission tomography scan. There was no other evidence of recurrence. The large right ventricular mass was associated with the right ventricle free wall, the apex, the papillary muscle, and the chordae to the tricuspid valve. After mass resection of the right ventricle, a one-and-a-half ventricular repair was performed with tricuspid valve replacement and defect closure. The patient was discharged on postoperative day 14 without complications and has been well for the first 3 months after the surgery.

From the *Division of Cardiothoracic Surgery, Department of Surgery, †Division of Pulmonary and Critical Care Medicine, Department of Medicine, ‡Department of Anesthesiology, and §Department of Radiology, Temple University School of Medicine, Philadelphia, PA USA.

The one-and-a-half ventricle repair technique has been used when the right ventricle (RV) is not capable of maintaining the entire pulmonary circulation. The primary concept of this surgery is to decrease RV preload by directing superior vena cava (SVC) blood flow into the pulmonary artery (PA) directly by cavopulmonary anastomosis. Various congenital heart diseases are treated with this procedure including pulmonary atresia with intact ventricular septum, Ebstein anomaly, and unbalanced atrioventricular canal defect. There are few case reports on this procedure for treatment of adult patients with Ebstein anomaly and infectious endocarditis.1,2

Although significant defects in RV morphology can be treated with this surgical technique, the long-term outcomes of this surgery have remained unknown. Recent reports showed good functional status without common late complications of the Fontan procedure such as recurrent cyanosis, pulmonary arteriovenous fistulas, chronic arrhythmias, and SVC syndrome.3,4

CASE REPORT

A 77-year-old woman with progressive shortness of breath was admitted with a history of coronary artery bypass grafting in 2004 and right upper lobectomy for squamous cell carcinoma, T2B N0 M0 of the lung cancer in 2012. Follow-up whole-body positron emission tomography scan at 1 year after lobectomy showed a possible intracardiac metastasis without any other evidence of recurrence (Fig. 1). Transthoracic echocardiography showed a large, irregular, fixed mass associated with the RV free wall and apex measuring 42 × 51 mm and moderate tricuspid regurgitation. Pulmonary perfusion studies were negative for perfusion abnormalities. Cardiac magnetic resonance imaging reported a large 42 × 61 × 44-mm mass in the region of the RV apex that had a markedly irregular nodular surface. T1 and T2 images suggest vascularity and an area of central necrosis. Myocardial infiltration of the mass could not be determined by magnetic resonance imaging (Fig. 2). Biopsy for the mass was not performed to avoid pulmonary embolism due to friability of the mass.

Elective surgery was scheduled for RV mass resection and RV construction with one-and-a-half ventricular repair as an option if the reconstructed RV could not support the entire pulmonary circulation. A right ventricular assist device was another option if pulmonary vascular resistance was high. Superior vena cava and inferior vena cava (IVC) pressures were monitored during surgery. Transesophageal echocardiography showed that the mass occupied 40% of the RV cavity (Fig. 3). After resternotomy, no pericardial effusion or metastatic invasive regions were observed. The 8 × 6 × 5-cm mass was found at the acute margin and the inferior wall of the RV. The tumor was indurated, encapsulated, and isolated, with no direct mass invasion into the chest wall. The right coronary artery at the atrioventricular groove was not affected by the mass. The direct pressure measurement of the PA was within normal range, and the mixed venous gas saturation was 80%. Although the mass seemed to be resectable, the limited remaining functional RV volume suggested the one-and-a-half ventricular repair option. The pulmonary vascular resistance was determined to be low enough for this procedure.

After full heparinization, cardiopulmonary bypass was started with aortic, bicaval cannulation as well as LV and PA venting. The anterior wall of the RV was opened adjacent to the mass with a safe margin (Fig. 4). The tumor was incised, taking parts of the anterior and the inferior wall with it. The mass involved the papillary muscle and the chordae tendineae, which was removed with the mass en bloc (Fig. 4). Frozen section showed metastatic moderately differentiated squamous cell carcinoma with extensive necrosis. All suspicious indurations at the margins were resected carefully. The defect was closed with a two-layer patch using CorMatrix (CorMatrix, Roswell, GA USA) inside and Hemashield graft (Boston Scientific, Natick, MA USA) outside with 4-0 Prolene running suture (Fig. 5). The tricuspid valve was replaced with a 27-mm Medtronic Mosaic valve (Medtronic, Inc, Minneapolis, MN USA) because of disruption of the chordae attached to the anterior leaflet. The SVC was divided distally to the SVC–right atrium junction. The proximal SVC stump was closed with 5-0 Prolene in two layers. The right PA was opened, and the distal SVC was anastomosed to it with 6-0 Prolene running suture in end-to-side fashion (Fig. 6). Cardiopulmonary bypass was weaned easily with small doses of epinephrine, milrinone, and inhaled nitric oxide. At the completion of surgery, the SVC and the IVC were 18 mm Hg and 10 mm Hg, respectively.

The patient was extubated on postoperative day (POD) 1. Inhaled nitric oxide was weaned off by POD 5 with SVC and IVC pressures of 15 mm Hg and 10 mm Hg, respectively. The patient did not show any heart failure symptom or cyanosis. The patient was discharged on POD 14 with Coumadin anticoagulation and has been well for the first 3 months after the surgery.

DISCUSSION

This procedure has been used for patients with complex congenital heart disease. However, the appropriate ventricular size or function for this approach still remains difficult to demonstrate. Van Arsdell et al5 mentioned that patients with a tricuspid Z value between −2 and −10 were considered for this repair. Muster and associates6 mentioned that ventricular outflow tract, right ventricular compliance, tricuspid regurgitation, and pulmonary vascular resistance as well as tricuspid Z value are important. In this case, the functional RV size and function after resection cannot be predicted because of tumor occupying the RV cavity. In general, we consider this procedure when there is an elevated central venous pressure immediately after bypass with borderline RV size and function.

This is a rare case of isolated RV metastasis after lung lobectomy for squamous cell carcinoma. Because the mass occupied almost half of the RV cavity, postoperative RV failure was a significant concern because of the size of residual RV. One-and-a-half ventricular repair was preferable to a right ventricular assist device in terms of quality of life, morbidity, and mortality. Intraoperative pressure measurement and mixed venous saturation data demonstrated the efficacy of one-and-a-half ventricular repair in this successful report on aggressive resection of an isolated RV metastatic tumor in a 77-year-old woman after right upper lobectomy.